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P-158 Stand up and be counted: working together to improve systems following medicine discrepancies
  1. Vicky Hill,
  2. Orlagh Sheils,
  3. Fiona Milne,
  4. Gail Riding and
  5. Dot Partington
  1. St Columba’s Hospice Care, Edinburgh, UK


Background Routine IPU audits (November 2022) identified medication issues and numerous complicated management systems. In addition, there was an increase in process-related medicine incidents reported. A similar situation in 2018 resulted in increased governance for Zopiclone and communication of concerns resulting in increased staff anxiety. Our learning from Psychological Safety (Edmondson. The fearless organization: creating psychological safety in the workplace for learning, innovation and growth. 2019) encouraged a different approach to the same issue.

Aims To use a systems-based approach (Healthcare Improvement Scotland. Safe management and use of controlled drugs report. 2014; Komashie, Ward, Bashford, et al. BMJ Open. 2021; 11: e037667) to encourage engagement with IPU staff to raise concerns, be part of the decision making and integral to the solution to improve the safety of medicines processes.

Methods Nov. 2022 – Multidisciplinary group formed (all IPU registered nurses invited). Dec. 2022 – Three key workflows identified: schedule 3–5 medication governance arrangements, use of patients’ own medicines and induction support. Jan. 2023 – Sub-group proposals considered. Feb. and Mar. 2023 – Planning and implementation of new processes and initial audit work. May 2023 onwards – Evaluation and feedback.

Results Governance arrangements: process now covers all schedule 3–5 medicines (Healthcare Improvement Scotland, 2014). Audit (April 2023) identified need for improved recording in registers for additional details within registers – repeat audit (May 2023) provided assurance of safe process in place. Feedback from staff continues and staff have openly discussed trust within medicine management processes(Edmondson, 2019; Jackson. J Adv Nurs. 2023 May 10).

Using patients’ own medicines: the benefits outweighed any disadvantages (Crowther, Wanklyn, Johnson, et al. BMJ Support Palliat Care. 2013; 3:A50) and supported the organisation’s environmental sustainability ambitions. Pharmacy team role developed to include medicines reconciliation process, supporting consistency. Improved induction and support: staff feedback identified the need for enhanced pharmacy support and a clear and extended mentorship structure to ensure consistent messaging to all new staff.

Conclusion Current indications from audit and incident reporting suggests improvement. Opportunities have continued to engage with staff. A systems-based approach ‘not hindered by fear’ (Edmondson, 2019) has supported joint working between clinical, quality assurance and leadership teams to achieve safer practices.

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